Analgesic effect of local anaesthetic in haemorrhoid banding: systematic review and meta-analysis.

PURPOSE: Rubber band ligation of haemorrhoids can be,painful and there is no consensus regarding the optimal analgesic strategy. This study aims to determine whether there is a difference in post-procedural pain in adults undergoing haemorrhoid banding who have received local anaesthetic, a pudendal nerve block or no regional or local analgesia. METHODS: MEDLINE, Embase, Google Scholar and clinical trial registries were searched for randomised trials of local anaesthetic or pudendal nerve block use in banding. Primary outcomes were patient-reported pain scores. The quality of the evidence was assessed using the GRADE approach. RESULTS: Seven studies were included in the final review. No articles were identified that studied pudendal nerve blocks. The difference in numerical pain scores between treatment groups favoured the local anaesthetic group at all timepoints. The mean difference in scores on a 10-point scale was at 1 h,-1.43 (95% CI-2.30 to-0.56, p < 0.01, n = 342 (175 in treatment group)); 6 h,-0.52 (95% CI-1.04 to 0.01, p = 0.05, n = 250 (130 in treatment group)); and 24 h,-0.31 (95% CI-0.82 to 0.19, p = 0.86, n = 247 (127 in treatment group)). Of reported safety outcomes, vasovagal symptoms proceeded to meta-analysis, with a risk ratio of 1.01 (95% CI 0.64-1.60). The quality of the evidence was rated down to 'low' due to inconsistency and imprecision. CONCLUSION: This review supports the use of LA for reducing early post-procedural pain following haemorrhoid banding. The evidence was limited by small sample sizes and substantial heterogeneity across studies. REGISTRATION: PROSPERO (ID CRD42022322234).

Use of pudendal nerve blocks in rubber band ligation of haemorrhoids: an Australia-wide cross-sectional analysis.

BACKGROUND: Surgeons vary in their approach to preventing pain post rubber band ligation (RBL) of haemorrhoids, with pudendal nerve blocks (PNB) being one analgesic strategy. No data exists on how commonly PNBs are used in RBL in Australia, and whether use varies by year and patient and hospital characteristics. METHODS: Aggregate data from the National Hospital Morbidity Database was obtained for all admissions for RBL in Australia from 2012 to 2021, with and without a PNB, overall and in relation to sex, age group, hospital remoteness, hospital sector, and year of procedure. Adjusted relative risks (adj. RR) of PNB were estimated using Poisson regression, mutually adjusting for all variables. RESULTS: Of the 346 542 admissions for RBL, 14013 (4.04%) involved a PNB. The proportion of patients receiving a PNB increased between 2012-2013 and 2020-2021, from 1.62% to 6.63% (adj. RR 3.99, CI 3.64-4.36). Patients most likely to receive a PNB were female (adj. RR 1.10; CI 1.07-1.14) aged 25-34 years (adj. RR 1.13; CI 1.01-1.26); in major-city (adj. RR 1.25 CI 1.20-1.30) and private hospitals (adj. RR 3.28 CI 3.13-3.45). CONCLUSION: This is the first published analysis of the use of PNB in RBL. Pudendal nerve block use has increased over time, with substantial variation in practice. Blocks were more than three times as likely to be used in private compared to public hospitals. If evidence supporting PNB use is established, equitable access to the procedure should be pursued.

Local anaesthetic infiltration in rubber band ligation of rectal haemorrhoids: study protocol for a three-arm, double-blind randomised controlled trial (PLATIPUS trial).

INTRODUCTION: Rubber band ligation ('banding') is a common approach for the management of symptomatic haemorrhoids. However, up to 90% of patients experience postprocedural pain, and there is no consensus regarding the optimal analgesic strategy. In practice, patients may receive submucosal local anaesthetic, pudendal nerve block or routine periprocedural analgesia. The aim of this study is to compare the efficacy of submucosal local anaesthetic, pudendal nerve block and routine analgesia for postprocedural pain in patients undergoing haemorrhoid banding. METHODS AND ANALYSIS: This is a multicentre, prospective, three-arm, double-blind randomised controlled trial of adults booked for haemorrhoid banding. Participants will be randomised to one of three groups in a 1:1:1 ratio: (1)submucosal bupivacaine injection; (2) pudendal nerve ropivacaine injection and (3) no local anaesthetic. The primary outcome is patient reported postprocedural pain (scored 0-10) from 30 min to 2 weeks. Secondary outcomes include postprocedural analgesia use, time to discharge, patient satisfaction, time to return to work and complications. A sample size of 120 patients is required to achieve statistical significance. ETHICS AND DISSEMINATION: This study received Human Research Ethics Approval from the Austin Health Human Research Ethics Committee (March 2022). Trial results will be submitted to a peer-reviewed journal, and presented at academic meetings. A summary of the trial results will be made available to study participants on request. TRIAL REGISTRATION NUMBER: ACTRN12622000006741p.

Navigating parenthood in the surgical profession: mixed-methods study.

BACKGROUND: Significant barriers exist to surgeons being good parents and parents being good surgeons, and these barriers are heightened for women. Considering the gender balance now present in postgraduate medical schools, it is critical that these barriers are overcome if surgery is to attract and retain applicants. This study aimed to investigate patterns of parenthood in surgery, explore associated attitudes and experiences, and identify barriers and solutions within an Australian and New Zealand context. METHODS: Surgeons and trainees were invited to participate in a survey and focus groups. Quantitative results were described, and textual responses and focus group transcriptions were analysed thematically. RESULTS: There were 261 survey respondents (62.8 per cent women, 37.2 per cent men) and six focus groups (34 participants). Of the survey respondents, 79.6 per cent of women and 86.5 per cent of men had children. Women were more likely to time childbirth around training or work, and most respondents without children attributed this to their career. Tensions between parenthood and surgery engendered guilt for surgeon-parents. Parenthood was often the 'elephant in the room' in training and employment discussions. Breaking the silence around parenthood and surgery made it more acceptable, normalising positive behaviour changes. The major barrier to parenthood and surgery was the lack of flexible training opportunities. Participants called for top-down establishment of mandated, stand-alone, permanent part-time training positions. CONCLUSION: Many barriers to parenthood in surgery are created by rigid workplace and professional structures that are reflective of male-dominated historical norms. A willingness to be flexible, innovative and rethink models of training and employment is central to change.

It is difficult for surgeons to be good parents and parents to be good surgeons. This is a problem because it means that fewer doctors may want to be surgeons. This study asked surgeons and trainee surgeons what it is like to do their job as a parent. They were asked about this on their own and in groups. It was found that it is more difficult for female surgeons to have children than male surgeons. Surgeons with children feel guilty that they are not able to do a good job both at work and at home. Surgeons often avoid talking about parenting at work, because it is not normal to do so and they are afraid that it will have a negative effect on their career. If surgeons can work part-time while training, it would enable them to better balance their responsibilities as surgeons and parents. At the moment, there are not many opportunities to train part-time in Australia and New Zealand. This study suggests that surgeons and hospitals should make sure that this becomes accessible and normal.

A pilot randomised controlled trial of patient education to improve umbilical cleanliness prior to laparoscopic surgery.

BACKGROUND: Before laparoscopic abdominal surgery, surgeons frequently remove debris from patients' umbilici to prevent it from passing into the abdomen and optimise skin antisepsis. This task irritates the skin, takes time and contaminates sterile equipment. This pilot randomised controlled trial aimed to inform a definitive study investigating whether patient education improves umbilical cleanliness in these patients. METHODS: To generate data on effect size and sample size, adult patients undergoing elective and emergency laparoscopic abdominal surgery were randomised to an intervention group, who received an education pack to clean their umbilicus prior to surgery, or a control group, who received no pack. Umbilical cleanliness was measured using a novel scale. To assess scale validity and reliability, all umbilici were scored by nine surgeons and surgical trainees using photographs and umbilici were swabbed to estimate bacterial load. Intervention acceptability was assessed via study consent and withdrawal rates and trial feasibility was evaluated using qualitative insights documented by investigators. RESULTS: Seventy-one percent (22/31) of the intervention group had clean umbilici versus 61% (19/31) in the control group. A definitive trial would require 712 participants to show statistical significance between study groups. The umbilical cleanliness scale had excellent interrater and test-retest reliability and a moderate degree of convergent validity with respect to bacterial load. The intervention was highly acceptable to participants, and theatre nurses and surgical trainees were central to trial feasibility. CONCLUSION: A definitive trial is warranted and would contribute to an evidence-based, standardised approach to preoperative care. Trial registration no. ACTRN12620000278932.